MontanaNursesAssociation ~ MEMBERSHIP APPLICATION

20 Old Montana State Highway Montana City, MT 59634

Phone 406-442-6710 Fax (406) 442-1841

Date / FOR MNA USE ONLY
Montana
Last Name / First Name / Middle Initial / Employer Name / State / District / Local Unit
( ) / $
Mailing Address / Work Phone Number / Payment Type / Amount / Check # if Applicable
CB
City / State / Zip Code / Date of Hire / Non-CB
( ) / Processing Dates:
Phone Number / School of Nursing / MNA
ANA
Date of Birth / Graduation Date / HR
Letter
Personal E-mail Address (Please print clearly) / Credentials
Membership Categories
Choose Only One / payment options
Choose Only One
M = Full Membership Dues______/

1. E-PAY - Monthly

/

2. Credit Card Payment - Monthly or Annually

Employed / Electronic Checking Account
Funds Transfer (EFT) / Monthly / Amount to Charge:
Relief / Annual $ / .

R = Reduced Membership Dues______(One Half of the Full Membership Dues)

/ / Account #: / /
Monthly EFT Authorization Signature
By signing on the line above, I authorize my Constituent Member Association (CMA/ANA) to withdraw monthly electronic payments of 1/12 of my annual dues and any additional service fees from my account.
Please enclose a check payable to ANA for the first month’s payment; the account designated by the enclosed check will be drawn on or after the 15th of each month.)
Not Employed
Full-time Student- Basic Degree
Expiration Date:
New Graduate
Applies only to your first year of membership.
Must apply within six months of graduating basic nursing education. / Month / Year
*By signing the Electronic Deduction Authorization, or the Automatic Credit Card Payment Authorization, you are authorizing ANA to change the amount by giving the above-signed thirty (30) days written notice. Above-signed may cancel this authorization upon receipt by ANA of written notification of termination twenty (20) days prior to deduction date designated above. Membership will continue unless this notification is received. ANA will charge a $5 fee for returned draft or chargeback. *State nurses association dues are not deductible as charitable contributions for tax purposes, but may be deductible as a business expense. However, that percentage of dues used for lobbying by MNA is not deductible as a business expense. Please check with MNA for the correct amount. / Credit Card Payment Authorization Signature
By signing on the line above, I authorize CMA/ANA to charge the credit card listed in the credit card information for the monthly dues on the 1st day of the month per month or when annual renewal is due.
62-years-of-age or over - Not earning more than Social Security allows.
S = Special Membership Dues______(One Quarter of the Full Membership Dues)
62-years of age or over - not employed / 3. Annual Payment- in- Full
Enclose check payable to MNA for annual amount
Totally Disabled
4. Payroll Deduction – monthly
If You Choose To Authorize Payroll Deduction Complete Section Below.
Montana Nurses Association ~ AUTHORIZATION FOR PAYROLL DEDUCTION OF MEMBERSHIP DUES
  • I, the undersigned, do hereby authorize ______Hospital/Clinic ~ District No. ______Local Unit # ______, to deduct sums equal to my membership dues, as certified by the Treasurer of the Montana Nurses Association Board of Directors, for the American Nurses Association and the Montana Nurses Association, andas well as a nominal service charge to MNA.
  • Deductions shall be in twelve equal installments from my earned or accrued wages. Money deducted is to be forwarded to the Montana Nurses Association for distribution to the three levels of the Association.

Name (printed): / Date of Hire:
Signature:
Address: / City: / State: / Zip Code: